The COPD evaluation MedicalTemplate is suitable for hospitalists, internal medicine physicians, family practice physicians, pulmonologists, and other health care providers that evaluate patients with known or suspected COPD in ambulatory or hospital settings.  This medical documentation template is a fillable Adobe PDF and is designed to improve the efficiency and quality of care in patient with COPD.  It is suitable for use as a history and physical, consult note, or follow up note. This MedicalTemplate contains detailed checklists for the severity of COPD symptoms, current and planned COPD therapy, and other features helpful for a comprehensive COPD treatment plan. How to use MedicalTemplates

Chronic Obstructive Pulmonary Disease Evaluation

Impact of COPD on the Healthcare system

The National Center for Health Statistics reports COPD to be the 4^th leading cause of death in the Unites States, causing 124,000 deaths per year.  Over 24 million Americans have COPD, and women are more likely than men to die from COPD.   The major risk factor for developing and dying from COPD is tobacco smoking.  COPD is responsible for over 1 million hospital admissions and $37 billion dollars in healthcare costs each year.  Due to the large numbers of Americans with COPD and the heath care costs associated with the treatment of COPD, this chronic lung disease is a focus of many quality improvement initiatives and pay for performance programs.

E & M Documentation Template

The COPD evaluation MedicalTemplate contains prompters and space for all the required elements for a E&M encounter such as a new patient evaluation, consult, or follow up note.

When completed, and in conjunction with a supporting level of medical decision making, this MedicalTemplate meets or exceeds the documentation requirements in the 1995 and 1997 Medicare Guidelines for E&M services for the highest level of service.

• History  Click here to learn about History Documentation

• When completed, this document is a comprehensive (highest) level history as defined in 1997 Guidelines for E&M Services.
  
• Chief complaint
• History of present illness
• Past medical and surgical history
• Social history
• Risk factors for disease (occupational exposures, smoking, and others)
  
• Family history
• Review of systems
• Yes/No checkboxes for clear and complete documentation
• Prompters for
• Increasing severity & signs of exacerbation of COPD
• Ventilator and BiPap settings
• IV medications for hospitalized patients



• Examination  Click here to learn about Physical Exam Documentation

• When completed, this document is a comprehensive (highest) level physical exam as defined in 1997 Guidelines for E&M Services.
  
• General Multisystem Exam OR Respiratory System Exam
• Checkboxes for pertinent negatives and common positive findings
  



• Medical Decision Making  Click here to learn about MDM Documentation

• Full page for adequate space with complex patients
  
• Easy Documentation with checkboxes 
• Review of labs, tests, imaging, old records
• Coordination of care
• Common diagnostic and therapeutic options
  
• Assessment and plan 

Medical Documentation References and Resources

• 1997 Documentation Guidelines for Evaluation and Management Services 
• 1995 Documentation Guidelines for Evaluation and Management Services 
• HGSA Documentation worksheet 
• Trailblazer Health documentation worksheet (for DE, MD, TX, VA, or the DC)
• Medicare Audit and/or Coding Worksheet
• TrailBlazer Medicare Audit and/or Coding Worksheet

Digital Health Record

The COPD follow up evaluation MedicalTemplate functions like all other PDF files, but they have editable text fields and working checkboxes.  This allows information to be typed in or pasted from other applications to fill out the template.

Filled MedicalTemplates can be printed and saved to a computer, USB drive, CD, DVD, or other storage device to create a digital health record for your patients.

To learn more about how MedicalTemplates can be used as a digital health record, click here.

Digital Signature Enabled

Pay for Performance

The COPD patient encounter template was designed to include Clinical Performance Measures for COPD developed by the Physician Consortium for Performance Improvement.

The Clinical Performance Measures for COPD can be downloaded from here.

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MedicalTemplates are in the Adobe PDF format, which requires the free Adobe Reader.  With Adobe Reader, these templates can be printed as many times as needed on paper meeting your specifications or the specifications of any clinic, hospital, or other health care facility.